1
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Quan K, Hu L, Zhang S, Jin Y, Wang D, Luo J, Ma Y, Mao Y, Zhu W. Association of preoperative aneurysmal wall enhancement with relief of chronic headache after surgical clipping of unruptured intracranial aneurysms. Eur Radiol 2024; 34:3009-3018. [PMID: 37857901 DOI: 10.1007/s00330-023-10303-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 10/21/2023]
Abstract
OBJECTIVE To investigate the association between chronic headache outcome and aneurysmal wall enhancement (AWE) on high-resolution vessel wall imaging (HR-VWI) in patients with unruptured intracranial aneurysms (UIAs) who underwent microsurgical clipping. METHODS Two hundred seventy-four UIA patients were retrospectively analyzed. Patients were grouped according to presence of AWE. AWE was subclassified as focal or uniform. Clinical and imaging data were recorded. Headache was evaluated using the 10-point numerical rating scale and Headache Impact Test-6 before and 6 months after surgery. RESULTS The proportions of patients reporting chronic headache in the no AWE, focal wall enhancement (FWE), and uniform wall enhancement (UWE) groups were 5.7%, 24.8%, and 41.8%, respectively. All patients in the UWE group who reported headache before surgery experienced headache improvement after surgery. Decrease in headache severity was greater in the UWE group than in the FWE group. Multivariate binary logistic regression showed that FWE (odds ratio (OR) 0.490; 95% confidence interval (CI), 0.262-0.917; p = 0.026) and small intraluminal thrombus (OR 0.336; 95% CI, 0.142-0.795; p = 0.013) were independent factors protective against preoperative headache. FWE (OR 0.377; 95% CI, 0.195-0.728; p = 0.004) and small intraluminal thrombus (OR 0.235; 95% CI, 0.088-0.630; p = 0.004) were independent predictors of no headache relief after surgery. CONCLUSIONS AWE on HR-VWI is associated with relief of chronic headache after surgical clipping in patients with UIAs. Incidence of chronic headache was highest in patients exhibiting UWE. These patients also experienced the greatest improvement in headache after surgical clipping. CLINICAL RELEVANCE STATEMENT This study revealed that high-resolution vessel wall imaging can demonstrate aneurysmal wall plaque and intraluminal thrombus, which may be prognostic imaging markers for chronic headache in patients with unruptured intracranial aneurysms. KEY POINTS • Aneurysmal wall enhancement may be associated with chronic headache. • Incidence of chronic headache was highest in patients with aneurysms exhibiting uniform wall enhancement. • Patients with aneurysms exhibiting uniform wall enhancement experienced the greatest improvement in headache after clipping.
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Affiliation(s)
- Kai Quan
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
| | - Liuxun Hu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 200040, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China
| | - Shichao Zhang
- School of Information Science and Technology, Fudan University, Shanghai, 200433, China
- Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention (MICCAI) of Shanghai, Shanghai, 200032, China
| | - Yufei Jin
- School of Information Science and Technology, Fudan University, Shanghai, 200433, China
- Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention (MICCAI) of Shanghai, Shanghai, 200032, China
| | - Dongdong Wang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jianfeng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, 200030, China
| | - Yu Ma
- School of Information Science and Technology, Fudan University, Shanghai, 200433, China.
- Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention (MICCAI) of Shanghai, Shanghai, 200032, China.
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, 12 Middle Wulumuqi Road, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 200040, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200040, China.
- Neurosurgical Institute of Fudan University, Shanghai, 200040, China.
- Shanghai Clinical Medical Center of Neurosurgery, Shanghai, 200040, China.
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2
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Bilton EJ, Mollan SP. Giant cell arteritis: reviewing the advancing diagnostics and management. Eye (Lond) 2023; 37:2365-2373. [PMID: 36788362 PMCID: PMC9927059 DOI: 10.1038/s41433-023-02433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.
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Affiliation(s)
- Edward J Bilton
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Transitional Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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3
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Chu CQ. Animal models for large vessel vasculitis - The unmet need. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2023; 4:4-10. [PMID: 37138652 PMCID: PMC10150876 DOI: 10.2478/rir-2023-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 02/19/2023] [Indexed: 05/05/2023]
Abstract
Our understanding of the pathogenesis of large vessel vasculitis (LVV) are mainly achieved by studying the arteries taken from temporal artery biopsy in giant cell arteries (GCA) or surgical or autopsy specimens in Takayasu arteritis (TAK). These artery specimens provide invaluable information about pathological changes in these conditions that GCA and TAK are similar but are distinctly different in immune cell infiltrate and distribution of inflammatory cells in anatomical locations. However, these specimens of established arteritis do not provide information of the arteritis initiation and early events which are impossible to obtain in human artery specimens. Animal models for LVV are needed but not available. Here, several approaches are proposed for experimentation to generate animal models to aid in delineating the interaction of immune reaction with arterial wall components.
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Affiliation(s)
- Cong-Qiu Chu
- Division of Arthritis and Rheumatic Diseases, Oregon Health & Science University, Portland, Oregon97239, USA
- Innovent Biologics (USA), Rockville, Maryland20850, USA
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4
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Monti S, Schäfer VS, Muratore F, Salvarani C, Montecucco C, Luqmani R. Updates on the diagnosis and monitoring of giant cell arteritis. Front Med (Lausanne) 2023; 10:1125141. [PMID: 36910481 PMCID: PMC9995793 DOI: 10.3389/fmed.2023.1125141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/09/2023] [Indexed: 02/25/2023] Open
Abstract
This mini-review offers a critical appraisal of the currently employed imaging or histopathological tools to diagnose and monitor giant cell arteritis (GCA). An overview of the most updated evidence and current application of color duplex ultrasonography (US), temporal artery biopsy (TAB), 18-fluorodeoxyglucose [18F] FDG-PET/CT, magnetic resonance imaging, and computed tomography angiography is provided. The main limitations of each tool, and the most relevant research developments are discussed. The review highlights the complementary value of the available modalities to ensure a correct diagnosis of GCA, and to provide valuable prognostic information. Novel evidence is accumulating to support the role of imaging, and particularly US, as a monitoring tool for the disease, opening new perspectives for the future management of large vessel vasculitis.
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Affiliation(s)
- Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy.,Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Valentin Sebastian Schäfer
- Clinic of Internal Medicine III, Department of Oncology, Hematology, Rheumatology and Clinical Immunology, University Hospital of Bonn, Bonn, Germany
| | - Francesco Muratore
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Carlomaurizio Montecucco
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy.,Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Raashid Luqmani
- Rheumatology Department, Nuffield Orthopaedic Centre, University of Oxford, Oxford, United Kingdom
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5
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Quigley J, Sammel AM, Laurent R, Brewer J, Hsiao E, Schembri G, Fraser CL. The Clinical Significance of Small Vessel Vasculitis on Temporal Artery Biopsies. J Neuroophthalmol 2022; 42:212-217. [PMID: 35195542 DOI: 10.1097/wno.0000000000001505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Giant cell arteritis (GCA) is the most common type of systemic vasculitis in the elderly. Untreated, it can lead to irreversible blindness. Its diagnosis relies on a temporal artery biopsy (TAB). However, a proportion of patients have small vessel vasculitis (SVV) on biopsy; the prognosis of which remains unclear. The aim of this study is to compare the clinical presentation and long-term outcomes of those with SVV with negative and positive biopsies to determine whether long-term corticosteroid therapy can be avoided in these patients. METHODS Post hoc analysis of patients with suspected GCA who underwent TAB and fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) scan as part of a prospective GCA and PET cohort. Patients were divided in to 3 groups based on TAB result: positive (inflammation in the main artery wall), negative (no inflammation), and SVV (isolated vasa vasorum or periadventitial SVV). Clinical, serological, and PET/CT data of patients with SVV were compared with those with positive and those with negative biopsies. RESULTS For the 58 eligible patients recruited between May 2016 and December 2017, 11 had SVV, 12 had positive, and 35 had negative biopsies. Patients with SVV had similar clinical, serological, and PET/CT findings to those with negative biopsies. Compared with those with positive biopsies, patients with SVV had lower erythrocyte sedimentation rate (25 vs 78 mm/hour; P = 0.02), platelet count (296 vs 385 ×109/L; P = 0.03), and a lower median total vascular score on PET/CT scan (1.0 vs 13.5; P = 0.01). Median prednisone dose was lower (4.8 vs 11.7 mg; P = 0.015) and fewer were on steroid-sparing agents (20% vs 67%; P = 0.043) at 6 months. The percentage of patients with a clinical diagnosis of GCA was similar between those with SVV (3/11, 27.3%) and those with negative biopsies (5/35, 14.3%; P = 0.374). CONCLUSIONS Patients with SVV on TAB had similar clinical features, PET/CT findings, and 6-month outcomes to those with negative biopsies. Small vessel vasculitis can be treated as equivalent to a negative biopsy when being considered for diagnosis and treatment of GCA.
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Affiliation(s)
- Julian Quigley
- Department of Intensive Care (JQ), Chris O'Brien Lifehouse, Sydney, Australia ; Department of Rheumatology (AMS), Prince of Wales Hospital, Randwick, Sydney, Australia ; Prince of Wales Clinical School (AMS), University of New South Wales, Randwick, Sydney, Australia ; Departments of Rheumatology (RL, JB, EH, GS), Nuclear Medicine and Anatomical Pathology, Royal North Shore Hospital, St Leonards, Sydney, Australia ; Northern Clinical School (RL, GS), University of Sydney, St Leonards, Sydney, Australia; and Save Sight Institute (CLF), Faculty of Health and Medicine, The University of Sydney, Sydney, Australia
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6
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Evangelatos G, Grivas A, Pappa M, Kouna K, Iliopoulos A, Fragoulis GE. Cranial giant cell arteritis mimickers: A masquerade to unveil. Autoimmun Rev 2022; 21:103083. [PMID: 35341973 DOI: 10.1016/j.autrev.2022.103083] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/23/2022] [Indexed: 12/20/2022]
Abstract
Giant cell arteritis (GCA) is a large-vessel vasculitis that affects cranial and extra-cranial arteries. Extra-cranial GCA presents mainly with non-specific symptoms and the differential diagnosis is very broad, while the cranial form has more typical clinical picture and physicians have a lower threshold for diagnosis and treatment. Although temporal artery biopsy (TAB) has an established role, ultrasound (US) is being increasingly used as the first-line imaging modality in suspected GCA. Vasculitides (especially ANCA-associated), hematological disorders (mainly amyloidosis), neoplasms, infections, atherosclerosis and local disorders can affect the temporal arteries or might mimic the symptoms of cranial GCA and produce US and TAB findings that resemble those of temporal vasculitis. Given that prompt diagnosis is essential and proper treatment varies significantly among these diseases, in this review we aimed to collectively present disorders that can masquerade cranial GCA.
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Affiliation(s)
- Gerasimos Evangelatos
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | - Alexandros Grivas
- Clinical Immunology-Rheumatology Unit, Fourth Department of Internal Medicine, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Pappa
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantina Kouna
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - Alexios Iliopoulos
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - George E Fragoulis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko Hospital, National and Kapodistrian University of Athens, Athens, Greece
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7
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Temporal Artery Vascular Diseases. J Clin Med 2022; 11:jcm11010275. [PMID: 35012016 PMCID: PMC8745856 DOI: 10.3390/jcm11010275] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 12/24/2021] [Accepted: 12/30/2021] [Indexed: 02/06/2023] Open
Abstract
In the presence of temporal arteritis, clinicians often refer to the diagnosis of giant cell arteritis (GCA). However, differential diagnoses should also be evoked because other types of vascular diseases, vasculitis or not, may affect the temporal artery. Among vasculitis, Anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis is probably the most common, and typically affects the peri-adventitial small vessel of the temporal artery and sometimes mimics giant cell arteritis, however, other symptoms are frequently associated and more specific of ANCA-associated vasculitis prompt a search for ANCA. The Immunoglobulin G4-related disease (IgG4-RD) can cause temporal arteritis as well. Some infections can also affect the temporal artery, primarily an infection caused by the varicella-zoster virus (VZV), which has an arterial tropism that may play a role in triggering giant cell arteritis. Drugs, mainly checkpoint inhibitors that are used to treat cancer, can also trigger giant cell arteritis. Furthermore, the temporal artery can be affected by diseases other than vasculitis such as atherosclerosis, calcyphilaxis, aneurysm, or arteriovenous fistula. In this review, these different diseases affecting the temporal artery are described.
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8
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Abstract
A 73-year-old man presented with unsteadiness and general malaise and later had problems with cognition. This was initially diagnosed as benign paroxysmal positional vertigo, but he was later found to have giant cell arteritis. Neurologists and physicians should be aware that giant cell arteritis can present with encephalopathy rather than the more typical features of headache, jaw pain and visual disturbance.
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Affiliation(s)
- Mathilde Pauls
- Addenbrooke's Hospital Department of Neurology, Cambridge, UK
| | - Mantegh Singh
- Addenbrooke's Hospital Department of Neurology, Cambridge, UK
| | - Peter Martin
- Addenbrooke's Hospital Department of Neurology, Cambridge, UK
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9
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Muratore F, Boiardi L, Cavazza A, Tiengo G, Galli E, Aldigeri R, Pipitone N, Cimino L, Bonacini M, Croci S, Salvarani C. Association Between Specimen Length and Number of Sections and Diagnostic Yield of Temporal Artery Biopsy for Giant Cell Arteritis. Arthritis Care Res (Hoboken) 2021; 73:402-408. [PMID: 32741116 DOI: 10.1002/acr.24393] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the association between specimen length and number of sections evaluated and the diagnostic yield of temporal artery biopsy (TAB) for giant cell arteritis (GCA). METHODS A pathologist reviewed all TABs performed for suspected GCA between January 1991 and December 2012. The blocks of all the inadequate and negative biopsy specimens were recut, and further slides at deeper levels were stained with hematoxylin and eosin in order to avoid missing inflammatory changes. RESULTS In total, findings from 662 TABs were included in the study (71% female; mean age 73.2 years). A total of 427 TAB specimens (65%) were classified as negative, and 235 (35%) were classified as positive for GCA. Compared to those with negative TAB results, patients with positive TAB results were older and more frequently female. There was no difference in postfixation TAB specimen length between TAB specimens negative and positive for GCA (mean 6.5 mm versus 6.9 mm; P = 0.068). Cuts of additional biopsy sections revealed inflammation at deeper levels in 26 of 408 TAB specimens (6.4%) originally reported as uninflamed. The inflamed section was the second in 14 TAB specimens, the third in 9 specimens, and the fourth in 3 specimens. Piecewise logistic regression identified 5 mm as the TAB specimen length change point for diagnostic sensitivity. Compared to a TAB specimen length of <5 mm, the age- and sex-adjusted odds ratio for positive TAB results in samples ≥5 mm long was 1.5 (95% confidence interval 1.0-2.0), P = 0.032. CONCLUSION A postfixation TAB specimen length of at least 5 mm should be sufficient to make a histologic diagnosis of GCA. In order not to miss inflammatory changes, at least 3 further sections at deeper levels should be evaluated in all negative TAB specimens.
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Affiliation(s)
- Francesco Muratore
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luigi Boiardi
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Alberto Cavazza
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giacomo Tiengo
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, and University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Galli
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, and University of Modena and Reggio Emilia, Modena, Italy
| | | | - Nicolò Pipitone
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Cimino
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Martina Bonacini
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Stefania Croci
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Carlo Salvarani
- Azienda Unità Sanitaria Locale IRCCS di Reggio Emilia, Reggio Emilia, and University of Modena and Reggio Emilia, Modena, Italy
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10
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11
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Evangelatos G, Fragoulis GE, Iliopoulos A. A Case of Microscopic Polyangiitis Presenting as Cranial Giant Cell Arteritis. Mediterr J Rheumatol 2021; 31:412-415. [PMID: 33521574 PMCID: PMC7841091 DOI: 10.31138/mjr.31.4.412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/15/2020] [Accepted: 06/30/2020] [Indexed: 11/22/2022] Open
Abstract
We present a case of a 63-year old man with microscopic polyangiitis (MPA) in which the initial clinical presentation resembled the cranial form of giant cell arteritis (GCA) (headache, jaw claudication, low grade fever and raised inflammation markers). Ultrasound of both superficial common temporal arteries revealed signs indicative of vessel wall inflammation. Based on clinical picture and compatible imaging findings, treatment with corticosteroids for GCA was started. After initial improvement and steroid tapering, lung infiltrations, mononeuritis of the right peroneal nerve and cutaneous necrosis appeared and p-Antineutrophil cytoplasmic antibodies (ANCA) turned out to be positive. Three intravenous cyclophosphamide pulses for MPA led in disease remission and maintenance treatment with azathioprine followed. Two years later, the patient has no symptoms and laboratory parameters are normal. This case highlights that MPA can affect temporal arteries and can masquerade as cranial GCA.
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Affiliation(s)
- Gerasimos Evangelatos
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - George E Fragoulis
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
| | - Alexios Iliopoulos
- Rheumatology Department, 417 Army Share Fund Hospital (NIMTS), Athens, Greece
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12
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Simon S, Ninan J, Hissaria P. Diagnosis and management of giant cell arteritis: Major review. Clin Exp Ophthalmol 2021; 49:169-185. [PMID: 33426764 DOI: 10.1111/ceo.13897] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/06/2020] [Accepted: 12/13/2020] [Indexed: 12/13/2022]
Abstract
Giant cell arteritis is a medical emergency because of the high risk of irreversible blindness and cerebrovascular accidents. While elevated inflammatory markers, temporal artery biopsy and modern imaging modalities are useful diagnostic aids, thorough history taking and clinical acumen still remain key elements in establishing a timely diagnosis. Glucocorticoids are the cornerstone of treatment but are associated with high relapse rates and side effects. Targeted biologic agents may open up new treatment approaches in the future.
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Affiliation(s)
- Sumu Simon
- Department of Ophthalmology and South Australian Institute of Ophthalmology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jem Ninan
- Department of Rheumatology, Modbury Public Hospital, Modbury, South Australia, Australia
| | - Pravin Hissaria
- Department of Immunology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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13
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Galli E, Muratore F, Boiardi L, Cavazza A, Salvarani C. Response to 'The Relevance of Restricted Inflammation in a TAB' by Griffin KJ et al. Semin Arthritis Rheum 2021; 51:e8-e9. [PMID: 33451760 DOI: 10.1016/j.semarthrit.2021.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/05/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Elena Galli
- University of Modena and Reggio Emilia, Modena
| | - Francesco Muratore
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL -IRCCS di Reggio Emilia
| | - Luigi Boiardi
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL -IRCCS di Reggio Emilia
| | - Alberto Cavazza
- Operative Unit of Pathologic Anatomy, Azienda USL -IRCCS di Reggio Emilia, Italy
| | - Carlo Salvarani
- University of Modena and Reggio Emilia, Modena; Rheumatology Unit, Department of Specialistic Medicine, Azienda USL -IRCCS di Reggio Emilia.
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14
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Akiyama M. Recognition of Rare, Atypical Manifestations Is Important for Diagnosis and Management of Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: Comment on the Article by Delaval et al. Arthritis Rheumatol 2020; 73:719. [PMID: 33191641 DOI: 10.1002/art.41590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/10/2020] [Indexed: 11/10/2022]
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15
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Delaval L, Terrier B. Reply. Arthritis Rheumatol 2020; 73:719-720. [PMID: 33191585 DOI: 10.1002/art.41592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Accepted: 11/04/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Laure Delaval
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Université de Paris, Paris, France
| | - Benjamin Terrier
- Hôpital Cochin, National Referral Center for Systemic and Autoimmune Diseases, Université de Paris, Paris, France
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16
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Galli E, Muratore F, Boiardi L, Restuccia G, Cavazza A, Catanoso M, Macchioni P, Spaggiari L, Casali M, Pipitone N, Fontana A, Girolimetto N, Croci S, Salvarani C. Significance of inflammation restricted to adventitial/periadventitial tissue on temporal artery biopsy. Semin Arthritis Rheum 2020; 50:1064-1072. [PMID: 32911285 DOI: 10.1016/j.semarthrit.2020.05.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/13/2020] [Accepted: 05/27/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To evaluate the characteristics and significance of inflammation restricted (RI) to the adventitial and/or periadventitial tissue on temporal artery biopsy (TAB). METHODS We studied a retrospective cohort of 80 patients with RI, extending our earlier series of 39 patients. For comparison purposes, we collected the same data from 254 patients with transmural inflammation (TMI) and 81 TAB-negative patients. A review of the literature was also performed. RESULTS A final diagnosis of giant cells arteritis (GCA) and/or polymyalgia rheumatica (PMR) was observed in 86% of patients with RI. Compared to TMI, GCA diagnosis was significantly less frequently observed in patients with RI and in those TAB-negative (p < 0.0001), while cranial manifestations were significantly less frequent (p = 0.001) and ESR and CRP values at diagnosis significantly reduced (p < 0.0001). PMR, permanent visual loss, and large vessel involvement at diagnosis were equally present in the 3 subgroups. The median duration of prednisone therapy, the cumulative prednisone dosages, and the relapse and long-term remission rates were similar between patients with GCA-RI and those with TMI. The positive likelihood ratios (LRs) of pathological evidence of RI at TAB for GCA or GCA/PMR diagnoses were 0.88 (CI, 0.61-1.27) and 1.15 (CI, 0.67-1.99), while that of inflammation limited to adventitia was 1.37 (CI, 0.59-3.19) and 3.77 (CI, 0.53-26.72). In the literature review, the positive LR of RI for GCA diagnosis was 0.92 (CI, 0.68-1.25). CONCLUSION A large part of the patients with RI have GCA/PMR, however, the diagnostic value of RI for GCA diagnosis is not relevant.
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Affiliation(s)
- Elena Galli
- University of Modena and Reggio Emilia, Modena, Italy
| | - Francesco Muratore
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Giovanna Restuccia
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Alberto Cavazza
- Operative Unit of Pathologic Anatomy, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Mariagrazia Catanoso
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Pierluigi Macchioni
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Lucia Spaggiari
- Department of Radiology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Massimiliano Casali
- Nuclear Medicine Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Antonio Fontana
- Unit of Vascular Surgery, Department of Specialistic and General Surgery, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Nicolò Girolimetto
- Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Stefania Croci
- Clinical Immunology, Allergy and Advanced Biotechnologies Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Carlo Salvarani
- University of Modena and Reggio Emilia, Modena, Italy; Rheumatology Unit, Department of Specialistic Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy.
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17
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Regola F, Cerudelli E, Bosio G, Andreoli L, Tincani A, Franceschini F, Toniati P. Long-term treatment with tocilizumab in giant cell arteritis: efficacy and safety in a monocentric cohort of patients. Rheumatol Adv Pract 2020; 4:rkaa017. [PMID: 32685912 PMCID: PMC7359771 DOI: 10.1093/rap/rkaa017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/04/2020] [Indexed: 01/06/2023] Open
Abstract
Objective The efficacy of tocilizumab (TCZ) in GCA is supported by two randomized controlled studies, in which TCZ allowed remission to be achieved after 52 weeks of treatment. However, after discontinuation of treatment, half of the patients relapsed. The aim of this study was to analyse the efficacy and safety of long-term treatment with TCZ and the role of fluorodeoxyglucose (FDG)-PET/CT scanning in the follow-up of these patients. Methods We collected the clinical data of a monocentric cohort of GCA patients retrospectively. Results Thirty-two patients were treated with TCZ [25 males and 7 females; age = 74 (59–81) years]. Most of them achieved and maintained clinical remission (1 month: 69%; 3 months: 91%; 6 months: 96%; 12 months: 100%), with serological and FDG-PET/CT scan improvement and a reduction of concomitant glucocorticoid therapy. Nineteen patients were treated for >52 weeks, and in 13 of them a dose tapering was performed, whereas in 2 cases TCZ was suspended for disease remission. Only two patients relapsed: one during TCZ tapering and one after TCZ discontinuation. Ten cases of mild infections and a case of urinary sepsis were reported; in patients treated for >1 year there was no increase in the incidence of side effects compared with patients treated for <12 months. Conclusion In our cohort of patients, we confirmed the efficacy of TCZ in the induction and maintenance of remission of GCA, demonstrating an important steroid-sparing effect and a good safety profile. Long-term treatment seems to prevent relapse of the disease, suggesting that TCZ treatment can be continued for >52 weeks with efficacy and safety.
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Affiliation(s)
- Francesca Regola
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia.,Department of Clinical and Experimental Sciences, University of Brescia
| | | | - Giovanni Bosio
- Nuclear Medicine Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia.,Department of Clinical and Experimental Sciences, University of Brescia
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia.,Department of Clinical and Experimental Sciences, University of Brescia
| | - Franco Franceschini
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia.,Department of Clinical and Experimental Sciences, University of Brescia
| | - Paola Toniati
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili di Brescia
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18
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Ponte C, Martins-Martinho J, Luqmani RA. Diagnosis of giant cell arteritis. Rheumatology (Oxford) 2020; 59:iii5-iii16. [DOI: 10.1093/rheumatology/kez553] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Abstract
GCA is the most common form of primary systemic vasculitis affecting older people. It is considered a clinical emergency because it can lead to irreversible blindness in around 20% of untreated cases. High doses of glucocorticoids should be initiated promptly to prevent disease-related complications; however, glucocorticoids therapy usually results in significant toxicity. Therefore, correct diagnosis is crucial. For many years, temporal artery biopsy has been considered the diagnostic ‘gold standard’ for GCA, but it has many limitations (including low sensitivity). US has proven to be effective for diagnosing GCA and can reliably replace temporal artery biopsy in particular clinical settings. In cases of suspected GCA with large-vessel involvement, other imaging modalities can be used for diagnosis (e.g. CT and PET). Here we review the current evidence for each diagnostic modality and propose an algorithm to diagnose cranial-GCA in a setting with rapid access to high quality US.
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Affiliation(s)
- Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria – Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon
- Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Joana Martins-Martinho
- Rheumatology Department, Hospital de Santa Maria – Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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19
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Evaluation of deeper levels in initially negative temporal artery biopsies and likelihood of a positive result. Ann Diagn Pathol 2020; 46:151517. [PMID: 32305002 DOI: 10.1016/j.anndiagpath.2020.151517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/24/2020] [Indexed: 11/21/2022]
Abstract
Giant cell arteritis is a vasculitis that affects large- and medium-sized vessels in patients over the age of 50 years. The demonstration of granulomatous arteritis is the criterion standard to establish a definitive diagnosis. However, temporal arteritis is known to discontinuously involve the artery, and there is no standardization of the number of sections which should be examined in a length of sampled artery. The goal of the study is to determine, if by examining additional sections from temporal artery (TA) biopsy cases initially interpreted as negative, do we uncover cases of vasculitis. We conducted a retrospective review of the clinical and histologic features of 75 consecutive temporal artery biopsy cases. Our findings showed that the vast majority (94%) of cases that were biopsy "proven" to be negative for temporal arteritis on initial examination remained negative after examination of all subsequent deeper levels (median of 337 total levels examined). These cases were less likely to show classical GCA signs and symptoms and typically presented at a younger age than the biopsy-positive cases. However, 4 (6%) of the initially "biopsy-negative" cases did turn out to be positive on deeper levels, with 56, 109, 346, and 590 total levels examined, respectively. At least 2 of these 4 patients did not receive prednisone or were weaned off prednisone treatment and experienced persistent/recurrent GCA symptoms. We conclude that routine sampling may miss the diagnosis in a subset of cases and in some cases, sectioning deeper into the paraffin block may be warranted.
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20
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Zhang Y, Wang D, Yin Y, Fan H, Zhang W, Zeng X. Clinical comparisons of patients with giant cell arteritis with versus without fever at onset. J Int Med Res 2019; 47:5613-5622. [PMID: 31547723 PMCID: PMC6862894 DOI: 10.1177/0300060519875379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective Giant cell arteritis (GCA) is the most common systemic vasculitis in individuals aged ≥50 years. Some patients with GCA who develop fever at onset without typical ischemic manifestations may be misdiagnosed with fever of unknown origin. Methods In the present study, we retrospectively evaluated the clinical records of patients with GCA. Patients with and without fever at onset were compared. Results This study included 91 patients with GCA, 55 of whom had fever at onset. The patients with fever at onset showed a lower frequency of jaw claudication and arthralgia and a higher percentage of constitutional symptoms than patients without fever. Additionally, their laboratory results revealed a lower percentage of positive anti-neutrophil cytoplasmic antibody. Furthermore, a lower proportion of affected intracranial vessels was found in patients with fever at onset. Finally, the proportion of biopsy-positive cases was higher in patients with than without fever at onset. Conclusions In this study, 60.4% of patients with GCA had fever at onset. Patients in this group usually had more severe inflammation with a potentially lower risk of ischemic accidents of the central nervous system than patients without fever at onset.
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Affiliation(s)
- Yun Zhang
- Department of General Internal Medicine, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Dongmei Wang
- Department of Neurology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yue Yin
- Department of General Internal Medicine, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Hongwei Fan
- Department of Infectious Disease, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital (PUMCH), Chinese Academy of Medical Science (CAMS) and Peking Union Medical College (PUMC), Beijing, China
| | - Xuejun Zeng
- Department of General Internal Medicine of Peking Union Medical College Hospital, Beijing, China
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21
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Hellmich B, Agueda A, Monti S, Buttgereit F, de Boysson H, Brouwer E, Cassie R, Cid MC, Dasgupta B, Dejaco C, Hatemi G, Hollinger N, Mahr A, Mollan SP, Mukhtyar C, Ponte C, Salvarani C, Sivakumar R, Tian X, Tomasson G, Turesson C, Schmidt W, Villiger PM, Watts R, Young C, Luqmani RA. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis 2019; 79:19-30. [PMID: 31270110 DOI: 10.1136/annrheumdis-2019-215672] [Citation(s) in RCA: 555] [Impact Index Per Article: 111.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Since the publication of the European League Against Rheumatism (EULAR) recommendations for the management of large vessel vasculitis (LVV) in 2009, several relevant randomised clinical trials and cohort analyses have been published, which have the potential to change clinical care and therefore supporting the need to update the original recommendations. METHODS Using EULAR standardised operating procedures for EULAR-endorsed recommendations, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 13 countries. We modified existing recommendations and created new recommendations. RESULTS Three overarching principles and 10 recommendations were formulated. We recommend that a suspected diagnosis of LVV should be confirmed by imaging or histology. High dose glucocorticoid therapy (40-60 mg/day prednisone-equivalent) should be initiated immediately for induction of remission in active giant cell arteritis (GCA) or Takayasu arteritis (TAK). We recommend adjunctive therapy in selected patients with GCA (refractory or relapsing disease, presence of an increased risk for glucocorticoid-related adverse events or complications) using tocilizumab. Methotrexate may be used as an alternative. Non-biological glucocorticoid-sparing agents should be given in combination with glucocorticoids in all patients with TAK and biological agents may be used in refractory or relapsing patients. We no longer recommend the routine use of antiplatelet or anticoagulant therapy for treatment of LVV unless it is indicated for other reasons. CONCLUSIONS We have updated the recommendations for the management of LVV to facilitate the translation of current scientific evidence and expert opinion into better management and improved outcome of patients in clinical practice.
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Affiliation(s)
- Bernhard Hellmich
- Department of Internal Medicine, Rheumatology and Immunology, Medius Kliniken, University of Tübingen, Kirchheim-Teck, Germany
| | - Ana Agueda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga E.P.E, Aveiro, Portugal
| | - Sara Monti
- Rheumatology, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Immunology, University Hospital Charité, Berlin, Germany
| | - Hubert de Boysson
- Internal Medicine, Centre Hospitalier Universitaire de Caen, Caen, Basse-Normandie, France
| | - Elisabeth Brouwer
- Rheumatology and Clinical Immunology, UMCG, Groningen, The Netherlands
| | | | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Christian Dejaco
- Rheumatology, Medical University Graz, Graz, Austria.,Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Nicole Hollinger
- Department of Internal Medicine, Rheumatology and Immunology, Medus Klinken, Karl-Albrechts-Universität Tübingen, Kirchheim-Teck, Germany
| | - Alfred Mahr
- Hospital Saint-Louis, University Paris Diderot, Paris, France
| | - Susan P Mollan
- Ophthalmology, University Hospitals Birmingham, Birmingham, UK.,Neurometabolism, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Chetan Mukhtyar
- Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Cristina Ponte
- Rheumatology, Hospital de Santa Maria - CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal.,Rheumatology Research Unit; Instituto de Medicina Molecular, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Rajappa Sivakumar
- Stroke and Neurocritical Care, GLB Hospitals and Acute Stroke Centers, Chennai, India
| | - Xinping Tian
- Rheumatology, Peking Union Medical College Hospital, Beijing, China
| | | | - Carl Turesson
- Department of Rheumatology, Skåne University Hospital, Malmö, Sweden
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | - Peter M Villiger
- Rheumatology and Clinical Immunology / Allerg, University Hospital (Inselspital), Bern, Switzerland
| | - Richard Watts
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
| | | | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
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22
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Macchioni P, Boiardi L, Muratore F, Restuccia G, Cavazza A, Pipitone N, Catanoso M, Mancuso P, Luberto F, Giorgi Rossi P, Salvarani C. Survival predictors in biopsy-proven giant cell arteritis: a northern Italian population-based study. Rheumatology (Oxford) 2018; 58:609-616. [DOI: 10.1093/rheumatology/key325] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 08/19/2018] [Indexed: 11/12/2022] Open
Abstract
Abstract
Objective
To evaluate the influence of disease-related findings and treatment outcomes on survival in a population-based cohort of Northern Italian patients with GCA.
Methods
A total of 281 patients with incident temporal artery biopsy (TAB)-proven GCA, diagnosed over a 26-year period (1986–2012) and living in the Reggio Emilia area, were retrospectively evaluated. We analysed clinical, imaging and laboratory findings at diagnosis, pathological patterns of TAB, CS treatment and therapeutic outcomes, and traditional cardiovascular risk factors as factors predictive of survival.
Results
Univariate analysis showed that increased mortality was associated with large vessel involvement at diagnosis [hazard ratio (HR) 5.84], while reduced mortality was associated with female sex (HR 0.66), PMR (HR 0.54), higher haemoglobin levels (HR 0.84) at diagnosis, long-term remission (HR 0.47) and inflammation limited to adventitia or to the adventitial vasa vasorum (HR 0.48) at TAB examination. Multivariate analysis confirmed the association between increased mortality and large vessel involvement (HR 5.14) at diagnosis, between reduced mortality and PMR (HR 0.57) at diagnosis and adventitial inflammation (HR 0.31) at TAB.
Conclusion
PMR at diagnosis and inflammation limited to the adventitia at TAB appear to identify subsets of patients with more benign disease, while large vessel involvement at diagnosis is associated with reduced survival.
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Affiliation(s)
- Pierluigi Macchioni
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Francesco Muratore
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Italy
| | - Giovanna Restuccia
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Alberto Cavazza
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Mariagrazia Catanoso
- Rheumatology Unit, Department of Specialistic Medicine, and Pathology Unit, Department of Oncology and Advanced Technology, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Pamela Mancuso
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Ferdinando Luberto
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Paolo Giorgi Rossi
- Interinstitutional Epidemiology Unit, Azienda USL-IRCCS di Reggio Emilia (Local Health Authority), Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Italy
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23
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Zhang Y, Wang D, Chu X, Zhang W, Zeng X. Differences in clinical manifestations and prognosis of Chinese giant cell arteritis patients with or without polymyalgia rheumatica. Ir J Med Sci 2018; 188:713-720. [DOI: 10.1007/s11845-018-1903-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 09/15/2018] [Indexed: 12/19/2022]
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24
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van der Geest KSM, Sandovici M, van Sleen Y, Sanders JS, Bos NA, Abdulahad WH, Stegeman CA, Heeringa P, Rutgers A, Kallenberg CGM, Boots AMH, Brouwer E. Review: What Is the Current Evidence for Disease Subsets in Giant Cell Arteritis? Arthritis Rheumatol 2018; 70:1366-1376. [PMID: 29648680 PMCID: PMC6175064 DOI: 10.1002/art.40520] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 03/29/2018] [Indexed: 12/14/2022]
Abstract
Giant cell arteritis (GCA) is an autoimmune vasculitis affecting large and medium‐sized arteries. Ample evidence indicates that GCA is a heterogeneous disease in terms of symptoms, immune pathology, and response to treatment. In the current review, we discuss the evidence for disease subsets in GCA. We describe clinical and immunologic characteristics that may impact the risk of cranial ischemic symptoms, relapse rates, and long‐term glucocorticoid requirements in patients with GCA. In addition, we discuss both proven and putative immunologic targets for therapy in patients with GCA who have an unfavorable prognosis. Finally, we provide recommendations for further research on disease subsets in GCA.
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Affiliation(s)
| | - Maria Sandovici
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Yannick van Sleen
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Jan-Stephan Sanders
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Nicolaas A Bos
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Wayel H Abdulahad
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Coen A Stegeman
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Heeringa
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Abraham Rutgers
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Cees G M Kallenberg
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Annemieke M H Boots
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
| | - Elisabeth Brouwer
- University of Groningen and University Medical Center Groningen, Groningen, The Netherlands
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25
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Zhao CL, Hui Y, Amin A. Temporal small arterial inflammation is common in patients with giant cell arteritis. Hum Pathol 2018; 81:65-70. [PMID: 29953896 DOI: 10.1016/j.humpath.2018.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/25/2018] [Accepted: 06/09/2018] [Indexed: 10/28/2022]
Abstract
Giant cell arteritis (GCA) primarily involves medium-to-large arteries. Small-vessel inflammation is a recognized phenomenon occurring in association with GCA. However, its significance is poorly elucidated. Histologic sections and medical records of105 temporal artery specimens were retrospectively reviewed between 2008 and 2017 to examine associated clinical manifestations and laboratory data including antinuclear antibody and p-antineutrophilic cytoplasmic antibody titers. Immunohistochemical staining for CD4 and CD8 was performed in select cases to assess the nature of the inflammatory response. Seventy-eight patients meeting the diagnostic criteria of temporal arteritis were included in the analysis. Twenty-eight specimens demonstrated temporal arteritis with small arterial inflammation (SAI), and 50 specimens showed temporal arteritis without SAI. Eight (28.6%) of 28 patients with SAI presented with jaw claudication, whereas 5 (17.9%) were febrile at presentation. In contrast, in 50 patients without SAI, jaw claudication and fever were seen in 11 and 2 cases, respectively (P = .01 and P = .0047, respectively). No statistically significant difference was noted between other symptoms and laboratory indices between the 2 groups. Elevated p-antineutrophilic cytoplasmic antibody titers in GCA may be associated with concomitant polymyalgia rheumatica or treatment-resistant disease. We also identified a higher count of CD4 and CD8 T cells in SAI cases, although the ratio of CD4/CD8 T lymphocytes was within normal limits. In conclusion, simultaneous involvement of arterioles and medium- to large-sized arteries is common in GCA and may be associated with treatment-refractory disease. Documentation of small arterial involvement in GCA will help the clinicians to manage the disease more effectively.
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Affiliation(s)
- Chaohui Lisa Zhao
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital/The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.
| | - Yiang Hui
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital/The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Ali Amin
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital/The Miriam Hospital, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
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26
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Luqmani R, Lee E, Singh S, Gillett M, Schmidt WA, Bradburn M, Dasgupta B, Diamantopoulos AP, Forrester-Barker W, Hamilton W, Masters S, McDonald B, McNally E, Pease C, Piper J, Salmon J, Wailoo A, Wolfe K, Hutchings A. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess 2018; 20:1-238. [PMID: 27925577 DOI: 10.3310/hta20900] [Citation(s) in RCA: 258] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9-61% of true cases. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. DESIGN Prospective multicentre cohort study. SETTING Secondary care. PARTICIPANTS A total of 381 patients referred with newly suspected GCA. MAIN OUTCOME MEASURES Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. RESULTS We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician's assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). LIMITATIONS There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. CONCLUSION We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. FUTURE WORK Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ellen Lee
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Surjeet Singh
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mike Gillett
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| | - Mike Bradburn
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | | | - Wulf Forrester-Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Shauna Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Brendan McDonald
- Department of Neuropathology and Ocular Pathology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eugene McNally
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Colin Pease
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jennifer Piper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - John Salmon
- Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Allan Wailoo
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Konrad Wolfe
- Department of Pathology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Ciccia F, Rizzo A, Ferrante A, Guggino G, Croci S, Cavazza A, Salvarani C, Triolo G. New insights into the pathogenesis of giant cell arteritis. Autoimmun Rev 2017; 16:675-683. [DOI: 10.1016/j.autrev.2017.05.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 03/17/2017] [Indexed: 12/12/2022]
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Ciccia F, Guggino G, Ferrante A, Cipriani P, Giacomelli R, Triolo G. Interleukin-9 and T helper type 9 cells in rheumatic diseases. Clin Exp Immunol 2017; 185:125-32. [PMID: 27159882 DOI: 10.1111/cei.12807] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 04/14/2016] [Accepted: 04/30/2016] [Indexed: 01/05/2023] Open
Abstract
Interleukin (IL)-9 is a 28-30 kDa monomeric glycosylated polypeptide belonging to the IL-7/IL-9 family of proteins that bind to a composite receptor consisting of the private receptor IL-9R and the IL-2 receptor, gamma (IL-2RG), a common gamma subunit shared by the receptors of many different cytokines. The IL-9R is expressed widely and IL-9 impacts a number of effector cells, such as effector T cells, B cells, innate lymphoid cells, mast cells, polymorphonuclear cells, epithelial cells and smooth muscle cells, playing an important role in regulating inflammatory immunity. The critical role of IL-9 in promoting cellular and humoral immune responses makes it an important focus of potential therapeutic interventions. Recently, a defined subset of T helper type cells, Th9 cells, has been identified by the potent production of IL-9. The involvement of the Th9 cell subset has been described in many types of inflammatory diseases, namely atopic diseases, helminth infections, experimental autoimmune encephalomyelitis and ulcerative colitis. In this review, we summarize the IL-9 biological activities, highlighting roles for IL-9 and Th9 cells in rheumatoid and psoriatic arthritis, systemic vasculitis, systemic lupus erythematosus and systemic sclerosis.
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Affiliation(s)
- F Ciccia
- Dipartimento Biomedico di Medicina Interna e Specialistica, Sezione di Reumatologia, University of Palermo, Palermo
| | - G Guggino
- Dipartimento Biomedico di Medicina Interna e Specialistica, Sezione di Reumatologia, University of Palermo, Palermo
| | - A Ferrante
- Dipartimento Biomedico di Medicina Interna e Specialistica, Sezione di Reumatologia, University of Palermo, Palermo
| | - P Cipriani
- Dipartimento di Scienze Cliniche Applicate e Biotecnologiche, Sezione di Reumatologia, Università di L'Aquila, L'Aquila, Italy
| | - R Giacomelli
- Dipartimento di Scienze Cliniche Applicate e Biotecnologiche, Sezione di Reumatologia, Università di L'Aquila, L'Aquila, Italy
| | - G Triolo
- Dipartimento Biomedico di Medicina Interna e Specialistica, Sezione di Reumatologia, University of Palermo, Palermo
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Le Pendu C, Meignin V, Gonzalez-Chiappe S, Hij A, Galateau-Sallé F, Mahr A. Poor Predictive Value of Isolated Adventitial and Periadventitial Infiltrates in Temporal Artery Biopsies for Diagnosis of Giant Cell Arteritis. J Rheumatol 2017; 44:1039-1043. [PMID: 28461644 DOI: 10.3899/jrheum.170061] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We investigated the diagnostic value of inflammation limited to the adventitia (ILA), and isolated vasa vasorum or small-vessel vasculitis (VVV, SVV) in temporal artery biopsies (TAB) for giant cell arteritis (GCA). METHODS Two pathologists reviewed consecutive first TAB. Using the clinical diagnoses as the gold standard, positive predictive values (PPV) were calculated. RESULTS Among the 75 patients without classic TAB features of GCA, 8 had GCA diagnoses. The PPV of ILA, VVV, and SVV seen by either or both pathologists were 17%, 0%, and 7%, and 17%, 0%, and 10%, respectively. CONCLUSION (Peri)adventitial infiltrates in TAB poorly predict GCA.
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Affiliation(s)
- Claire Le Pendu
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France.,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM
| | - Véronique Meignin
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France.,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM
| | - Solange Gonzalez-Chiappe
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France.,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM
| | - Adrian Hij
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France.,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM
| | - Françoise Galateau-Sallé
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France.,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM
| | - Alfred Mahr
- From the Department of Internal Medicine, Unit for Systemic Diseases (UF07), and Department of Pathology, and Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM, Paris; Department of Pathology, University Hospital Caen, Caen; Department of Biopathology, Léon-Bérard Cancer Center, Lyon, France. .,C. Le Pendu, MD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; V. Meignin, MD, Department of Pathology, Saint-Louis University Hospital; S. Gonzalez-Chiappe, MD, MPH, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital; A. Hij, MD, Department of Internal Medicine, Unit for Autoimmune and Vascular Diseases (UF04), Saint-Louis University Hospital; F. Galateau-Sallé, MD, PhD, Department of Pathology, University Hospital Caen, and Department of Biopathology, Léon-Bérard Cancer Center; A. Mahr, MD, MPH, PhD, Department of Internal Medicine, Unit for Systemic Diseases (UF07), Saint-Louis University Hospital, and ECSTRA Team, Epidemiology and Biostatistics, Sorbonne Paris Cité Research Center UMR 1153, INSERM.
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Zuckerman R, Patel M, Alpert DR. A tale of two vasculitides: biopsy-proven giant cell arteritis followed by the independent development of renal-limited microscopic polyangiitis. BMJ Case Rep 2017; 2017:bcr-2017-219228. [PMID: 28432167 DOI: 10.1136/bcr-2017-219228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
We describe an 80-year-old woman who presented with headaches, bilateral jaw claudication and visual symptoms. She was diagnosed with giant cell arteritis, which was confirmed by temporal artery biopsy. She was treated with high-dose prednisone followed by a slow taper, with complete resolution of symptoms. Approximately 4 years later, she developed progressively worsening renal function associated with haematuria. Serological workup revealed a high-titre perinuclear antinuclear cytoplasmic antibody and antibodies to myeloperoxidase. Renal biopsy demonstrated a pauci-immune focal crescentic glomerulonephritis. Extensive review of systems, physical exam and diagnostic studies demonstrated no evidence of extra-renal disease, and she was diagnosed with renal-limited microscopic polyangiitis. High-dose prednisone was resumed, but she refused treatment with either cyclophosphamide or rituximab due to concern for toxicity. Her prednisone dose was tapered and renal function stabilised. Our case highlights the need to recognise the successive occurrence of two distinct vasculitides in a single patient and monitor accordingly.
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Affiliation(s)
- Roman Zuckerman
- Medicine, Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Mayur Patel
- Medicine/Nephrology, Jersey Shore University Medical Center, Neptune, New Jersey, USA
| | - Deborah R Alpert
- Medicine/Rheumatology, Jersey Shore University Medical Center, Neptune, New Jersey, USA
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Catanoso M, Macchioni P, Boiardi L, Muratore F, Restuccia G, Cavazza A, Pipitone N, Mancuso P, Luberto F, Salvarani C. Incidence, Prevalence, and Survival of Biopsy-Proven Giant Cell Arteritis in Northern Italy During a 26-Year Period. Arthritis Care Res (Hoboken) 2017; 69:430-438. [DOI: 10.1002/acr.22942] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/23/2016] [Accepted: 05/17/2016] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Luigi Boiardi
- Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
| | | | | | - Alberto Cavazza
- Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
| | - Nicolò Pipitone
- Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
| | - Pamela Mancuso
- Azienda USL di Reggio Emilia and Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
| | - Ferdinando Luberto
- Azienda USL di Reggio Emilia and Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
| | - Carlo Salvarani
- Azienda Ospedaliera IRCCS di Reggio Emilia; Reggio Emilia Italy
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Is all inflammation within temporal artery biopsies temporal arteritis? Hum Pathol 2016; 57:17-21. [PMID: 27445262 DOI: 10.1016/j.humpath.2016.07.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/17/2016] [Accepted: 07/02/2016] [Indexed: 11/20/2022]
Abstract
Temporal arteritis peaks during the eighth decade, affecting patients with frequent comorbidities who are especially prone to adverse effects of corticosteroid therapy. Perivascular inflammation involving small periadventitial vessels is not uncommon in otherwise normal temporal artery biopsies (TABs). As ischemic events occur in patients with non-temporal artery--based inflammation, it has been recommended that any vascular inflammation within TABs be treated with corticosteroids. We sought to determine whether such patients are at increased risk for temporal arteritis-like adverse events compared with age-matched controls devoid of inflammatory infiltrates. TABs without transmural temporal arteritic damage accessioned between 2002 and 2012 were reviewed for inflammation (>15 perivascular lymphocytes) involving small blood vessels and/or temporal artery adventitia. Of 343 TABs, 278 (81%) were negative for transmural arteritis. Inflammation involving small vessels and/or temporal artery adventitia was present in 56 cases (20%). Age-matched controls were available for 39 cases. With a mean follow-up of 5 years (range, 1-11 years), 6/39 (15%) of patients developed stroke or cardiovascular events or died compared with 7/39 (18%) of age-matched controls. None of the patients with study-positive TAB had documented steroid therapy before or after TAB. Our results demonstrate that patients with inflammation involving only small vessels or temporal artery adventitia are not at increased risk for temporal arteritis-like adverse events, and suggest that the risks of protracted corticosteroid therapy in this elderly population likely exceed any potential benefits. We advise against diagnosing vasculitis in the absence of temporal arteritic damage.
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Muratore F, Boiardi L, Cavazza A, Aldigeri R, Pipitone N, Restuccia G, Bellafiore S, Cimino L, Salvarani C. Correlations between histopathological findings and clinical manifestations in biopsy-proven giant cell arteritis. J Autoimmun 2016; 69:94-101. [PMID: 27009904 DOI: 10.1016/j.jaut.2016.03.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Revised: 03/09/2016] [Accepted: 03/09/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To correlate histopathological features of positive temporal artery biopsy (TAB) and clinical manifestations of the disease in a large single-center population-based cohort of patients with biopsy-proven giant cell arteritis (GCA). METHODS A pathologist with expertise in vasculitis and blinded to clinical data and final diagnosis reviewed all TABs performed for suspected GCA at our hospital between January 1986 and December 2013. Histopathologic features evaluated were: the severity of inflammation and intimal hyperplasia, both graded on a semiquantitative scale (mild = 1, moderate = 2, severe = 3), the presence of intraluminal acute thrombosis, calcifications, giant cells, fibrinoid necrosis and laminar necrosis. RESULTS 274 patients had a final diagnosis of biopsy-proven GCA and were included in the study. Cranial ischemic events (CIEs) were observed in 161 (58.8%), visual manifestations in 79 (28.8%) and permanent (partial or complete) visual loss in 51 (18.6%) patients. Predictors for the development of CIEs were older age (OR = 1.057, 95% CI 1.019-1.097, p = 0.003), lower ESR values (OR = 0.990, 95% CI 0.981-0.999, p = 0.026) as well as the presence of giant cells (OR = 1.848, 95% CI 1.045-3.269, p = 0.035) and laminar necrosis at TAB (OR = 2.334, 95% CI 1.187-4.587, p = 0.014). Predictors for the development of permanent visual loss were lower CRP values (OR = 0.906, 95% CI 0.827-0.992, p = 0.033) and the presence of calcifications at TAB (OR = 3.672, 95% CI 1.479-9.121, p = 0.005). Fibrinoid necrosis was not observed in any of the TABs evaluated. CONCLUSION Pathological features of TAB may predict some manifestations of GCA. These findings may have implications for patients' management.
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Affiliation(s)
- Francesco Muratore
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Alberto Cavazza
- Pathology Unit, Department of Oncology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Raffaella Aldigeri
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Giovanna Restuccia
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Salvatore Bellafiore
- Pathology Unit, Department of Oncology, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Luca Cimino
- Ophthalmology Unit, Department of Surgery, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy.
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Management of giant cell arteritis: Recommendations of the French Study Group for Large Vessel Vasculitis (GEFA). Rev Med Interne 2016; 37:154-65. [DOI: 10.1016/j.revmed.2015.12.015] [Citation(s) in RCA: 126] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 11/17/2022]
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Hernández-Rodríguez J, Murgia G, Villar I, Campo E, Mackie SL, Chakrabarty A, Hensor EMA, Morgan AW, Font C, Prieto-González S, Espígol-Frigolé G, Grau JM, Cid MC. Description and Validation of Histological Patterns and Proposal of a Dynamic Model of Inflammatory Infiltration in Giant-cell Arteritis. Medicine (Baltimore) 2016; 95:e2368. [PMID: 26937893 PMCID: PMC4778989 DOI: 10.1097/md.0000000000002368] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/25/2015] [Accepted: 11/28/2015] [Indexed: 11/26/2022] Open
Abstract
The extent of inflammatory infiltrates in arteries from patients with giant-cell arteritis (GCA) have been described using different terms and definitions. Studies investigating the relationship between GCA histological features and clinical manifestations have produced controversial results. The aims of this study were to characterize and validate histological patterns in temporal artery biopsies (TABs) from GCA patients, to explore additional histological features, including the coexistence of different patterns, and also to investigate the relationship of the inflammatory patterns with clinical and laboratory features.We performed histological examination of TAB from patients with GCA consecutively diagnosed between 1992 and 2012. Patterns of inflammation were defined according to the extent and distribution of inflammatory infiltrates within the artery. Clinical and laboratory variables were recorded. Two external investigators underwent a focused, one-day training session and then independently scored 77 cases. Quadratic-weighted kappa was calculated.TAB from 285 patients (200 female/85 male) were evaluated. Four histological inflammatory patterns were distinguished: 1 - adventitial (n = 16); 2 - adventitial invasive: adventitial involvement with some extension to the muscular layer (n = 21); 3 - concentric bilayer: adventitial and intimal involvement with media layer preservation (n = 52); and 4 - panarteritic (n = 196). Skip lesions were observed in 10% and coexistence of various patterns in 43%. Raw agreement of each external scorer with the gold-standard was 82% and 77% (55% and 46% agreement expected from chance); kappa = 0.82 (95% confidence interval [CI] 0.70-0.95) and 0.79 (95% CI 0.68-0.91). Although abnormalities on temporal artery palpation and the presence of jaw claudication and scalp tenderness tended to occur more frequently in patients with arteries depicting more extensive inflammation, no statistically significant correlations were found between histological patterns and clinical features or laboratory findings.In conclusion, we have described and validated 4 histological patterns. The presence of different coexisting patterns likely reflects sequential steps in the progression of inflammation and injury. No clear relationship was found between these patterns and clinical or laboratory findings. However, several cranial manifestations tended to occur more often in patients with temporal arteries exhibiting panarteritic inflammation. This validated score system may be useful to standardize stratification of histological severity for immunopathology biomarker studies or correlation with imaging.
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Affiliation(s)
- José Hernández-Rodríguez
- From the Vasculitis Research Unit, Department of Autoimmune Diseases (JHR, GM, IV, CF, SPG, GEF, MCC); Department of Anatomic Pathology, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (EC); Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust (SLM, EMAH, AWM); Leeds Teaching Hospitals NHS Trust, Leeds, UK (AC); Department of Internal Medicine, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain (JMG)
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Ratzinger G, Zelger BG, Carlson JA, Burgdorf W, Zelger B. Das Vaskulitis-Rad - ein algorithmischer Ansatz für kutane Vaskulitiden. J Dtsch Dermatol Ges 2015. [DOI: 10.1111/ddg.20_12859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Gudrun Ratzinger
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Innsbruck; Innsbruck Österreich
| | | | - J. Andrew Carlson
- Department of Pathology; Divisions of Dermatology and Dermatopathology, Albany Medical College; Albany New York USA
| | - Walter Burgdorf
- Abteilung für Dermatologie und Allergologie; Ludwig-Maximilians-Universität München; München Deutschland
| | - Bernhard Zelger
- Universitätsklinik für Dermatologie und Venerologie; Medizinische Universität Innsbruck; Innsbruck Österreich
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Ratzinger G, Zelger BG, Carlson JA, Burgdorf W, Zelger B. Vasculitic wheel - an algorithmic approach to cutaneous vasculitides. J Dtsch Dermatol Ges 2015; 13:1092-117. [DOI: 10.1111/ddg.12859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Gudrun Ratzinger
- Department of Dermatology and Venereology; Medical University Innsbruck; Innsbruck Austria
| | | | - J. Andrew Carlson
- Department of Pathology; Divisions of Dermatology and Dermatopathology; Albany Medical College; Albany New York
| | - Walter Burgdorf
- Department of Dermatology and Allergology; Ludwig Maximilian University; Munich Germany
| | - Bernhard Zelger
- Department of Dermatology and Venereology; Medical University Innsbruck; Innsbruck Austria
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Espígol-Frigolé G, Prieto-González S, Alba MA, Tavera-Bahillo I, García-Martínez A, Gilabert R, Hernández-Rodríguez J, Cid MC. Advances in the diagnosis of large vessel vasculitis. Rheum Dis Clin North Am 2015; 41:125-40, ix. [PMID: 25399944 DOI: 10.1016/j.rdc.2014.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The diagnosis of large-vessel vasculitis has experienced substantial improvement in recent years. While Takayasu arteritis diagnosis relies on imaging, the involvement of epicranial arteries by giant-cell arteritis facilitates histopathological confirmation. When appropriately performed temporal artery biopsy has high sensitivity and specificity. However, an optimal biopsy is not always achievable and, occasionally, the superficial temporal artery may not be involved. Imaging in its various modalities including colour-duplex ultrasonography, computed tomography angiography, magnetic resonance angiography and positron emission tomography, are emerging as important procedures for the diagnosis and assessment of disease extent in large-vessel vasculitis. Recent contributions to the better performance and interpretation of temporal artery biopsies as well as advances in imaging are the focus of the present review.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Marco A Alba
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Itziar Tavera-Bahillo
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Ana García-Martínez
- Vasculitis Research Unit, Emergency Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Villarroel 170, Barcelona 08036, Spain
| | - Rosa Gilabert
- Center for Diagnostic Imaging, Hospital Clínic, Institut d'Investigacions Biomèdiques Pi i Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - José Hernández-Rodríguez
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain
| | - Maria C Cid
- Vasculitis Research Unit, Department of Systemic Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), University of Barcelona, Villarroel 170, Barcelona 08036, Spain.
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Ciccia F, Rizzo A, Guggino G, Cavazza A, Alessandro R, Maugeri R, Cannizzaro A, Boiardi L, Iacopino DG, Salvarani C, Triolo G. Difference in the expression of IL-9 and IL-17 correlates with different histological pattern of vascular wall injury in giant cell arteritis. Rheumatology (Oxford) 2015; 54:1596-604. [DOI: 10.1093/rheumatology/kev102] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Indexed: 12/24/2022] Open
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Inflamed temporal artery: histologic findings in 354 biopsies, with clinical correlations. Am J Surg Pathol 2014; 38:1360-70. [PMID: 25216320 DOI: 10.1097/pas.0000000000000244] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We reviewed 888 temporal artery biopsies (TAB) performed in 871 patients in a single institution from January 1986 to December 2013. Forty-four biopsies (4.9%) were inadequate, 490 (55.2%) were devoid of inflammation and were considered negative, and 354 (39.9%) showed inflammation and were considered positive. On the basis of the localization of the inflammation, positive TABs were further classified into 4 categories: small vessel vasculitis (SVV), in which inflammation was limited to small periadventitial vessels devoid of muscular coat, with sparing of the temporal artery (32 cases, 9% of the positive biopsies); vasa vasorum vasculitis (VVV), in which inflammation was limited to the adventitial vasa vasorum (23 cases, 6.5% of the positive biopsies); inflammation limited to adventitia (ILA), in which inflammation extended from a strictly perivascular localization to the surrounding adventitia, without medial involvement (25 cases, 7% of the positive biopsies); and transmural inflammation (TMI), in which inflammation crossed the external elastic lamina and extended to the media (274 cases, 77.5% of the positive biopsies). In TMI, inflammation was generally more prominent between media and adventitia and mostly consisted of T lymphocytes and macrophages, with occasionally a significant number of plasma cells. Numerous eosinophils or neutrophils (with or without leucocytoclasia and suppurative necrosis), fibrinoid necrosis (limited to small branches of the temporal artery), and acute thrombosis were unusual, being present in 8%, 1.8%, 0.7%, and 9.5% of our biopsies with TMI, respectively. Giant cells, laminar necrosis, and calcifications prevailed along the internal elastic lamina and were present in 74.8%, 25.2%, and 20% of the biopsies with TMI, respectively. Among the 322 patients with positive TAB on whom we obtained clinical information, 317 had giant cell arteritis and 5 had a different disease: 3 (with SVV at histology) had ANCA-associated vasculitis, 1 (with SVV with amyloid deposits) had primary systemic amyloidosis, and 1 (with TMI limited to a small branch) had polyarteritis nodosa. In none of these cases the biopsy showed fibrinoid necrosis or significant numbers of eosinophils or neutrophils. Considering the 317 patients with giant cell arteritis, those with SVV and VVV compared with those with TMI had a significantly lower frequency of cranial manifestation (including headache, jaw claudication, and abnormalities of temporal arteries), lower serum levels of acute-phase reactants, and a reduced frequency of prednisone therapy at the time of TAB, of the "halo sign" at color duplex sonography of temporal arteries, and of systemic symptoms (for VVV). Polymyalgia rheumatica and blindness were equally represented in all patients groups, whereas there was a higher frequency of male sex and peripheral arthritis in patients with SVV. Patients with ILA were more similar to those with TMI, having a lower frequency of headache, of abnormalities of temporal arteries, and of a positive "halo sign" at color duplex sonography of temporal arteries. In conclusion, the histologic spectrum of inflammatory lesions that can be found in TAB is broad, and the differences have clinical implications.
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Lally L, Pernis A, Narula N, Huang WT, Spiera R. Increased rho kinase activity in temporal artery biopsies from patients with giant cell arteritis. Rheumatology (Oxford) 2014; 54:554-8. [PMID: 25213129 DOI: 10.1093/rheumatology/keu364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Aberrant rho kinase (ROCK) activity is implicated in the pathogenesis of several vascular diseases and is associated with Th17 differentiation. Th17 immune response is recognized in the pathogenesis of GCA. The aim of this study was to assess ROCK activity in GCA. METHODS All patients who underwent temporal artery biopsy (TAB) at a tertiary care centre over 5 years were identified and charts reviewed. Subjects were categorized into three groups: TAB-positive GCA, TAB-negative GCA and age- and sex-matched controls. TABs were stained for phosphorylated ezrin/radixin/moesin (pERM), a surrogate of ROCK activity, and reviewed by a pathologist blinded to clinical status. Three areas were scored for staining intensity on a scale of 0-2, with a maximum possible score of 6. RESULTS Nineteen subjects with TAB-positive GCA, 17 with TAB-negative GCA and 18 controls were analysed. Compared with controls, GCA subjects with either positive or negative TABs had significantly higher pERM intensity scores (P = 0.0109). Adjusting for diabetes, hypertension, prednisone and statin use, GCA subjects still had higher pERM scores [odds ratio 7.3 (95% CI 1.9, 25.9), P = 0.0046]. The high pERM score had a sensitivity of 90% and a negative predictive value of 91% for the diagnosis of GCA in those with a negative TAB, compared with 51% sensitivity for histopathology alone. CONCLUSION Subjects with GCA had more intense pERM staining in TAB specimens compared with age- and sex-matched controls, regardless of whether TAB was positive or negative by routine histopathology, suggesting increased ROCK activity in GCA. The ROCK pathway warrants further investigation in GCA, as it may have diagnostic significance in enhancing the sensitivity of TAB.
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Affiliation(s)
- Lindsay Lally
- Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA. Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA.
| | - Alessandra Pernis
- Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA. Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA
| | - Navneet Narula
- Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA
| | - Wei-Ti Huang
- Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA
| | - Robert Spiera
- Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA. Department of Rheumatology, Hospital for Special Surgery, Department of Medicine, Weill-Cornell Medical College, Autoimmunity and Inflammation Program, Hospital for Special Surgery and Department of Clinical Pathology and Laboratory Medicine, Weill-Cornell Medical College, New York, NY, USA
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Affiliation(s)
- Jonathan H. Smith
- Kentucky Neuroscience Institute; University of Kentucky; Lexington KY USA
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Germano G, Muratore F, Cimino L, Lo Gullo A, Possemato N, Macchioni P, Cavazza A, Pipitone N, Boiardi L, Salvarani C. Is colour duplex sonography-guided temporal artery biopsy useful in the diagnosis of giant cell arteritis? A randomized study. Rheumatology (Oxford) 2014; 54:400-4. [DOI: 10.1093/rheumatology/keu241] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Shoda H, Morita K, Kanda H, Fujio K, Yamamoto K. An elderly woman with peripheral spondyloarthritis with aortitis. Mod Rheumatol 2014; 24:353-6. [DOI: 10.3109/14397595.2013.852845] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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45
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Pazzola G, Boiardi L, Casali B, Farnetti E, Nicoli D, Pipitone N, Padovano I, Caruso A, Catanoso M, Salvarani C. CC chemokine receptor 5 polymorphism in Italian patients with giant cell arteritis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0751-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Barba T, Pasquet F, Nibaud A, Maïs L, Hot A, Pavic M, Mahr A. [Prolonged fever in a 62-year-old man]. Rev Med Interne 2013; 35:206-9. [PMID: 24080237 DOI: 10.1016/j.revmed.2013.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 06/22/2013] [Indexed: 10/26/2022]
Affiliation(s)
- T Barba
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France.
| | - F Pasquet
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Nibaud
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - L Maïs
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Hot
- Service de médecine interne, hôpital Édouard-Herriot, 5, place d'Arsonval, 69003 Lyon, France
| | - M Pavic
- Service de médecine interne - oncologie, HIA Desgenettes, 108, boulevard Pinel, 69003 Lyon, France
| | - A Mahr
- Service de médecine interne, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75475 Paris, France
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Muratore F, Boiardi L, Restuccia G, Macchioni P, Pazzola G, Nicolini A, Germanò G, Possemato N, Cavazza A, Cavuto S, Cimino L, Pipitone N, Catanoso M, Addimanda O, Salvarani C. Comparison between colour duplex sonography findings and different histological patterns of temporal artery. Rheumatology (Oxford) 2013; 52:2268-74. [PMID: 24046471 DOI: 10.1093/rheumatology/ket258] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To assess the findings of temporal artery colour duplex sonography (CDS) in GCA characterized by a histological pattern of periadventitial small vessel vasculitis (SVV) and/or vasa vasorum vasculitis (VVV) and compare it with those observed in classic GCA with transmural vasculitis. METHODS We studied 30 patients with SVV and/or VVV, 63 patients with classic GCA and 67 biopsy-negative patients identified over a 9-year period. CDS of the temporal arteries was performed in all patients by one ultrasonographer. Temporal artery biopsy was used as the reference standard. Sensitivities, specificities and likelihood ratios (LRs) were calculated. RESULTS The frequency of the halo sign on CDS was significantly lower in the patients with SVV and/or VVV compared with those with classic GCA (20% vs 82.5%, P = 0.0001). The halo sign had a sensitivity of only 20% (95% CI 8.4, 39.1%) and a specificity of 80.6% (95% CI 68.7, 88.9%) for the diagnosis of SVV and/or VVV. The negative LR was 0.992 (CI 0.824, 1.195), and the positive LR was 1.030 (CI 0.433, 2.451). The halo sign for the diagnosis of biopsy-proven classic GCA had a higher sensitivity of 82.5% (CI 70.5, 90.5%), the same specificity of 80.6% (CI 68.7, 88.9%) and a higher positive LR (4.253; CI 2.577, 7.021). CONCLUSION The halo sign is infrequently found in GCA characterized by a histological pattern of SVV and/or VVV. This limits the sensitivity of CDS in correctly identifying patients with GCA.
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Affiliation(s)
- Francesco Muratore
- Rheumatology Unit, IRCSS - Arcispedale Santa Maria Nuova, Viale Risorgimento 80, 42100 Reggio Emilia, Italy.
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Marie I. Maladie de Horton et pseudopolyarthrite rhizomélique : critères diagnostiques. Rev Med Interne 2013; 34:403-11. [DOI: 10.1016/j.revmed.2013.02.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
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Atzeni F, Boiardi L, Vaglio A, Nicoli D, Farnetti E, Palmisano A, Pipitone N, Martorana D, Moroni G, Longhi S, Bonatti F, Buzio C, Salvarani C. TLR-4 and VEGF polymorphisms in chronic periaortitis. PLoS One 2013; 8:e62330. [PMID: 23690937 PMCID: PMC3653916 DOI: 10.1371/journal.pone.0062330] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Accepted: 03/20/2013] [Indexed: 11/19/2022] Open
Abstract
Objective Chronic periaortitis (CP) is a rare disease that is characterised by fibro-inflammatory tissue surrounding the abdominal aorta and has both non-aneurysmal (idiopathic retroperitoneal fibrosis [IRF]) and aneurysmal forms (inflammatory abdominal aortic aneurysm [IAAA]). We investigated whether toll-like receptor 4 (TLR-4) and vascular endothelial growth factor (VEGF) polymorphisms were associated with susceptibility to, and the clinical features of CP. Methods One hundred and two CP patients and 200 healthy controls were molecularly genotyped for TLR-4 gene polymorphism (+896 A/G) (rs4986790), VEGF mutations +936 C/T (rs3025039) and −634 C/G (rs2010963), and an 18 base pair (bp) insertion/deletion (I/D) polymorphism at −2549 of the VEGF promoter region. The patients were grouped on the basis of the type of CP (IRF or IAAA), and the presence or absence of established atherosclerotic disease (ischemic heart disease, cerebrovascular disease, and peripheral arterial disease). Results There were no significant differences in the distribution of the studied polymorphisms between the patients and controls. However, carriage of the +936 T allele was significantly more frequent in the patients with IRF than in those with IAAA (26.5% vs 5.3%; p = 0.046; OR 6.49 [95% CI 0.82–51.54]). There were significantly more carriers of the I allele among the patients with ureteral obstruction (83.8% vs 58.8%; p = 0.006; OR 3.63 [95% CI 1.42–9.28]) and those who received conservative treatment (48.5% vs 23.5%; p = 0.015; OR 3.06 [95% CI 1.22–7.721]) than among those without, and II homozygosity was significantly more frequent in the patients with deep vein thrombosis than in those without (30.4% vs 11.7%, p = 0.031; OR 3.31 [95% CI 1.07–10.21]). Conclusion The VEGF +936 C/T polymorphism may be associated with an increased risk of developing the non-aneurysmal IRF form of CP. Carriers of the I allele and II homozygosity are respectively at increased risk of developing ureteral obstruction and deep vein thrombosis.
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Affiliation(s)
- Fabiola Atzeni
- Rheumatology Unit, L. Sacco University Hospital of Milan, Milan, Italy
| | - Luigi Boiardi
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Augusto Vaglio
- Unit of Nephrology, University Hospital of Parma, Parma, Italy
| | - Davide Nicoli
- Laboratory of Molecular Biology, Arcispedale S Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Enrico Farnetti
- Laboratory of Molecular Biology, Arcispedale S Maria Nuova, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | | | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
| | - Davide Martorana
- Unit of Molecular Genetics, University Hospital of Parma, Parma, Italy
| | - Gabriella Moroni
- Nephrology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico Hospital, Policlinico Hospital, Milan, Italy
| | - Selena Longhi
- Nephrology Unit, Istituto di Ricovero e Cura a Carattere Scientifico Policlinico Hospital, Policlinico Hospital, Milan, Italy
| | - Francesco Bonatti
- Unit of Molecular Genetics, University Hospital of Parma, Parma, Italy
| | - Carlo Buzio
- Unit of Nephrology, University Hospital of Parma, Parma, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
- * E-mail:
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[Temporal arteritis: a field of research perspective]. Rev Med Interne 2013; 34:389-91. [PMID: 23541139 DOI: 10.1016/j.revmed.2013.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Accepted: 02/18/2013] [Indexed: 11/23/2022]
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